Physiotherapeutic Management of Hand-Foot Syndrome During Chemotherapy: a Case Report Autor para correspondência: Gabrielle Peres Paines

doi:10.21203/rs.3.rs-3886314/v1

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Physiotherapeutic Management of Hand-Foot Syndrome During Chemotherapy: a Case Report Autor para correspondência: Gabrielle Peres Paines

https://doi.org/10.21203/rs.3.rs-3886314/v1

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Objectives

To evaluate the management of hand-foot syndrome due to chemotherapy treatment by using physiotherapeutic intervention based on photobiomodulation.

Methodology:

This is a case report of a female patient who was treated at the Physiotherapy outpatient clinic of a Teaching Hospital at the country side of the State of RS and was diagnosed with Grade III invasive ductal mammary carcinoma in the right breast. Approved by the Federal University of Santa Maria's Ethics and Research Committee, number 48881321.4.0000.5346, Red and infrared LED at 4 J/cm2 were applied to the plantar surfaces of the hands and feet once a week as part of the standard physiotherapeutic treatment, which also included proprioceptive, resistance, and aerobic activities.

Results

An improvement in skin features was seen right away after the initial application, cell regeneration and epithelial neoformation, peeling on the plantar surface of the hands and feet, a decrease in hyperemia, and a pain-relieving effect. On the palm side of the hands, complete skin peeling, a decrease in edema, hyperemia, and discomfort were seen after the second application. Plantar hyperkeratosis on the foot completely disappeared, and there was a decrease in edema, hyperemia, burning, and pain. Finally, total rejuvenation of the skin on the plantar surface of the palms and soles of the feet was seen, enabling the recovery of previously impossible daily activities. Additionally, it enabled the continuation of chemotherapeutic treatments.

Conclusion

The hand-foot condition brought on by chemotherapy could be effectively treated with physical therapy and photobiomodulation employing red and infrared LEDs.

Cancer

Chemotherapy

Adverse effects

Palmar-plantar erythrodysesthesia

The number of cases of cancer, one of the leading causes of mortality worldwide, is on the rise. Treatment options can offer a cure, remission, or the greatest possible quality of life extension. Those options rely on the type and stage of the tumor, its location, and the patient's overall health. However, the degree, duration, and range of illnesses that the disease and its required therapy might produce varies depending on each patient [1, 2].

Breast tumors are one of the cancers with the highest incidence and fatality rates in women. Due to the possibility to completely remove the tumor and increase patients survival, surgery is typically the first course of treatment chosen. Among surgical approaches, sectorectomy, extended resection, or quadrantectomy are considered conservative options, while mastectomy is not. Radiotherapy, chemotherapy, and hormone therapy also stand out in addition to these [3, 4].

The side effects of breast cancer treatment might have a negative impact on quality of life. Chemotherapy is the form of treatment that most adversely affects the quality of life of patients with breast cancers, which can have a detrimental impact on the treatment due to its toxicity [5].

Antineoplastic chemotherapy is the administration of chemical substances to treat various types of cancer. Its primary goal is to eradicate the cancer cells responsible for tumor growth using drugs that act directly on bodily cells and are unable to distinguish between benign and malignant cells. As a result, chemotherapy treatment may have side effects that show up both physically and psychologically [6].

Hand-foot syndrome (MPS) is one of the side effects that may call for certain therapies or adjustments to the cancer treatment regimen. SMP, also known as palmar-plantar erythrodysesthesia, is a side effect of various chemotherapy medications that is a significant clinical issue. Although the exact mechanisms behind SMP's onset are still unknown, medications such capecitabine, 5-fluorouracil, doxorubicin, docetaxel, paclitaxel, and cytarabine have typically been related to the condition [7].

Symptoms vary according to the classification, which can vary in three degrees, the most typical symptoms are itching, discomfort, edema, and erythema in the palms of the hands and/or soles of the feet. Grade 1 is defined as minor skin changes or painless dermatitis, grade 2 is defined as skin changes without discomfort interfering with everyday activities, and grade 3 is defined as ulcerative dermatitis or skin alterations make everyday tasks more difficult because of sore skin [7, 8].

There are currently no known medicines for treating MPS; instead, reports focus solely on symptom management. According to research, topical treatments, dose reductions, or even stopping chemotherapy are the most efficient ways to reduce symptoms. Aqueous aloe vera cream in a neutral base and ointments with urea or lanolin as bases produce positive effects. To further reduce inflammation, discomfort, and hyperkeratosis, high-potency topical corticosteroids and topical keratolytics are also used as control measures [1, 2, 7].

Although photobiomodulation (FBM) with red and infrared LEDs is a technique frequently used in tissue regeneration, there is still limited research on how effective it is at managing the symptoms of SMP [9]. Consequently, researches that seek to define the advantages of these resources in SMP are crucial. Considering this background, the current study sought to examine the effects of photobiomodulation-based physiotherapeutic intervention in the treatment of hand-foot syndrome brought on by chemotherapy.

Female patient, 53 years old, diagnosed in August 2021 with invasive ductal breast carcinoma, unspecified type, grade III, in the right breast. Oncologic treatment was neoadjuvant chemotherapy from October 2021 to April 2022, with subsequent quadrandectomy-type surgery in May 2022. Adjuvant therapy included capecitabine chemotherapy and 15 radiotherapy sessions, which was completed in October 2022. In August 2022, she was referred to the outpatient physical therapy clinic complaining of fatigue with minor exertion, impairment in activities of daily living, and classic signs and symptoms of hand-foot syndrome such as pain, burning, and difficulty performing hand and foot movements that interfered with performing activities, including walking, raising the possibility of interrupting chemotherapy. During physiotherapy assessment, the following steps were performed: On inspection, the surgical scar was found to be in good condition, without significant adhesions; the skin of the thoracic region with mild erythema, classified as grade I radiodermatitis. On palpation, the surgical scar was in good condition, without adhesions, and the skin around the scar showed mild erythema, consistent with grade I radiodermatitis. Goniometry of the right upper extremity (MSD) revealed flexion (150°), extension (45°), and abduction (149°). Left upper extremity (MSE) goniometry revealed flexion (170°), extension (40°), and abduction (130°). Perimetry revealed no changes consistent with signs of lymphedema.

Initial treatment consisted of two weekly physiotherapy sessions aimed at maintaining and improving range of motion, reducing symptoms of cancer-related fatigue (CRF), and reducing symptoms of hand-foot syndrome such as burning pain. hyperesthesia, hyperemia, and scaly tissue changes. The established procedures for physical therapy treatment were: active kinesitherapy for the upper limbs, aerobic exercise with an ergometric treadmill or stationary bicycle, with progressive intensity (mild, moderate, vigorous), and FBM with LED for hand-foot syndrome.

The FBM protocol on the palmar surface was performed with the Endophoton® device - KLD – Brazil, with continuous mode and punctual technique. The applicator cluster has an effective irradiation area of 7.85 cm², with twelve LED points, power of 0.04 W per point, total power of 0.48 W per irradiation area, with 6 red LED points with a wavelength of 658 nm and 6 infrared with 858 nm. The dose used was 4 J/cm² for both wavelengths, with an average application time of 1 minute and 20 seconds at each point, with a distance of 1 cm between points. A Sportllux Advanced® LED blanket with 72 LEDS was applied on the sole of the foot, 36 with a wavelength of 660 ± 20nm (red) and 36 with a wavelength of 850 ± 20nm (infrared). The average power of each LED is 8 mW, total 0.58 W per irradiation area, at a dose of 4 J/cm² and a duration of 10 minutes (parameters provided by the manufacturer of the device cannot be changed), on the sole of the foot and toes.

Kinesiotherapy consisted of a combined protocol of free exercises with a stick, a ball, dumbbells, and elastic bands, with progressive loading and resistance. The exercises aimed to raise the upper limbs above head level, in addition to exercises with a Swiss ball for trunk control and breathing exercises, consisting of 3 series of 10 to 15 repetitions each. Aerobic exercises were performed for 20 minutes on a treadmill or a bicycle, increasing the training heart rate (HR). Maximum heart rate was determined by calculation: HRmax = 220-age, keeping a target value HR of 60 to 70% of HRmax and a perceived exertion between 13 and 16 based on the scale BORG. In the first 10 minutes, the exertion intensity was 13–14; in the remaining 10 minutes, the exertion intensity was increased to 15–16. The physiotherapy protocol, established twice a week, was alternated, with kinesitherapy and aerobic exercise on one day and the second session focused on treating the symptoms of SMP with photobiomodulation. In addition, the patient was asked to maintain continuity of activities at home to support the physiotherapy treatment.

After the first week of physiotherapy, a significant improvement in SMP symptoms was observed. The patient reported a reduction in the burning sensation and pain on the palm and soles of his feet, allowing her to perform pinching movements with her hands and walk longer. As for the appearance of the skin, a decrease in the cyanotic color on the extremities was observed. After 4 weeks, improvement in skin integrity was observed with complete resolution of plantar hyperkeratosis, even with continued chemotherapy treatment.

After the fourth application (four weeks), it was observed that after the formation of a crust with initial thickening and subsequent peeling of the skin, there were characteristic signs of improved vascularization, increased proliferation of epithelial cells, possible proliferation of fibroblasts (fibroplasia) and skin regeneration, culminating in restoration of vitality and positive effects on skin quality. These benefits were also observed with the continuation of adjuvant chemotherapy, with the patient reporting a significant improvement in burning sensation and absence of pain at the end of the fourth application, allowing her to resume daily activities and continue chemotherapy. It was recommended that skin care be continued and hydration with moisturizers be maintained according to physician recommendations, in addition to guidance on physical exercise, which is essential for maintaining range of motion and managing cancer fatigue. The results are shown in images 1 and 2 before and after a week of treatment. Figure 3 displays the outcome following the fourth intervention.

The symptoms of CRF improved from the second session, even in the first week of treatment, with the protocol of combined physical exercises of moderate to high intensity. The patient reported a reduction in the sensation of fatigue and pain, as well as an improvement in the perception of effort, which allowed a better adaptation to the proposed exercises. In this way, the treatment had a positive effect on quality of life, ensuring a greater ability to perform daily activities.

The aim of this study was to analyze the effects of a physiotherapeutic intervention based on photobiomodulation in the treatment of hand-foot syndrome secondary to chemotherapy. Hand-foot syndrome is an adverse reaction to certain chemotherapies manifested by erythema, edema, and pain on the palms and soles of the feet. Compared to other adverse effects of cancer treatment, the incidence of SMP is lower at about 60%, which is why treatment modalities have not yet been clarified and success rates are low [1].

Skin integrity is the most important factor in diagnosis. The palms of the hands and the soles of the feet have a high concentration of sudoriferous ducts, which allows greater accumulation of drugs in these regions. Due to the toxicity of chemotherapeutic agents, oxidative damage and free radicals occur, leading to the symptoms of SMP. Therefore, it is essential to inspect the skin before, during, and after the use of chemotherapy drugs to favor the prevention or identification of the syndrome and prevent it from developing into more severe symptoms and affecting the quality of life and/or continuity of treatment [1, 2].

This study showed positive effects when FBM was used in conjunction with kinesiotherapy for the treatment of SMP in a 4-week protocol. After the first session, there was improvement in the symptoms of burning and pain on the palms and soles of the feet, as well as a reduction in the cyanotic color of the extremities. During the 2nd and 3rd weeks of treatment, a crust formed and increased in thickness. At the end of the 4th week, a significant improvement in vascularization and skin regeneration was observed, allowing a full return to daily activities and continuation of chemotherapy.

The FBM has the ability to stimulate cell metabolism and proliferation, which has a positive effect on healing. Physiologically, FBM is able to decrease the production of reactive oxygen species (ROS) and increase the levels of nitric oxide (NO), a vasodilator substance, which improves blood flow to the irradiated tissue. As a result, the tissue is better oxygenated and cell migration is promoted, contributing to tissue regeneration [10, 11].

Positive effects of FBM on pain symptoms in patients with MPS have already been demonstrated. Among the recommendations of the World Association of Photobiomodulation Therapy (WALT) for the treatment of MPS is FBM with red (630–680 nm) or infrared (800–1100 nm) wavelengths applied 2 to 3 times per week for a period of 2 to 4 weeks to achieve better results [11]. In a pilot study, the FBM protocol was performed in 31 patients with SMP. The wavelength used was in the red spectrum (660 nm), with a dose of 2 J/cm² in the palms and soles, three times per week, for two weeks. Pain decreased and satisfaction with treatment increased in 49% of patients treated with FBM [12].

Physical activity has a positive effect on cancer survivors and is considered a safe therapy to manage fatigue, improving the quality of life of breast cancer survivors and benefiting psychosocial and physical factors in these patients [13]. In the present report, the reduction of symptoms related to SMP allowed patients to perform the exercises, which led to an improvement in the perception of effort. Consistent with the results of the present study, a combined exercise program with patients undergoing breast cancer treatment showed a reduction in FRC. The study included high-intensity aerobic and resistance exercises that resulted in significant increases in lower limb muscle strength and improvements in the perception of fatigue [14]. Thus, it can be concluded that both aerobic training and combined training improve HRR by increasing physical conditioning, such as aerobic capacity, muscular strength and endurance, and flexibility. However, the protocol must be standardized and individualized for each patient in terms of intensity and volume of exercise to achieve better results [15].

Based on the characteristics and peculiarities of the physical therapy outpatient clinic, as well as the complications presented by the patient in question, her other clinical manifestations were considered, resulting in the adaptation of the FBM physical therapy protocol to 1 session per week for 4 weeks, with the other session of physical therapy consisting of active and aerobic exercises. However, in contrast to the aforementioned studies, the implementation of the aforementioned protocol proved to be an effective solution for the present situation.

A limitation of the study is the uncertainty of the dose fraction delivered by the LED blanket, which contains 72 LED points, 36 in the red and 36 in the infrared waveband. The total dose reported in the devices is 4 J/cm² per irradiation area, but the plantar surface does not occupy the entire area of the blanket. Therefore, it is not possible to specify the total dose delivered by the device.

In the preparation of the present study, it was found that further research is needed on the treatment of MMP, especially with regard to FBM parameters such as dose and number of applications. In addition, despite studies demonstrating the benefits of physical activity, no defined protocols have been described to support the treatment of SMP. There is still a large gap in the literature on SMP, as little is known in research and clinical practice, and there is still no convincing evidence of the effects of FBM on this change.

Chemotherapy carries the risk of developing SMP as a side effect, and depending on the severity of symptoms, it may be necessary to interrupt it, jeopardising the chances of success of oncologic treatment. The treatment of SMP remains uncertain, however the most common approach is to recover from symptoms by using corticosteroid medications to reduce inflammation, analgesics to relieve pain, and cosmetics to hydrate the skin. Thus, the results of this study show that FBM combined with active and aerobic exercise has positive effects on the treatment of grade III SMP and could be a treatment alternative. However, further studies are needed to establish specific protocols for each grade of MMP, specifying the dose, frequency and number of applications.

Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Financial interests: The authors have no relevant financial or non-financial interests to disclose.

Author Contributions: All authors contributed to the study. All authors read and approved the final manuscript.

Ethics approval: This study was performed in line with the principles of the Declaration of Helsinki. Approved by the Federal University of Santa Maria's Ethics and Research Committee, number 48881321.4.0000.5346.

Consent to participate: Informed consent was obtained from participant included in the study.

Consent to publish: The authors affirm that human research participant provided informed consent for publication of the images in Figures 1, 2 and 3.

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No competing interests reported.

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Physiotherapeutic Management of Hand-Foot Syndrome During Chemotherapy: a Case Report Autor para correspondência: Gabrielle Peres Paines

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